Well-managed warfarin is superior to NOACs.

Limitations of the NOAC randomized controlled trial (RCT) evidence base The multinational NOAC RCTs demonstrated noninferiority to warfarin at and below the following mean international normalized ratio (INR) time in therapeutic range (TTR): 64% for dabigatran in the RELY (Randomized Evaluation of Long-term Anticoagulation Therapy) trial ; 55% for rivaroxaban in the Rocket-AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial ; and 62% for apixaban in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial. There is no statistically significant RCT evidence to support the noninferiority of the NOACs over well-managed warfarin at a mean TTR greater than 64%.